| NPI | 1942511928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 1867) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MA 0149) |
| Enumeration Date | 2010-06-24 |
| Last Update Date | 2020-02-10 |